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Radar on Market Access: Kansas Works Out Medicaid Expansion Deal

Posted by Lauren Flynn Kelly on Jan 21, 2020

Kansas Gov. Laura Kelly (D) and Republican Senate Majority Leader Jim Denning on Jan. 9 said they’d reached a compromise proposal to extend Medicaid coverage to an estimated 130,000 more low-income Kansans, AIS Health reported.

If approved, Kansas will pursue a full expansion of Medicaid to 138% of the Federal Poverty Level (FPL) with a 90/10 funding match. The state will also seek Section 1332 waiver approval to establish a reinsurance program and Section 1115 waiver approval to transition individuals whose incomes fall between 100% and 138% of the FPL from Medicaid to the exchange no later than Jan. 1, 2022, although expansion is not dependent on those waivers. If CMS denies either waiver, full Medicaid expansion will be implemented on Jan. 1, 2021, according to a summary of the pending legislation.

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Topics: Industry Trends, Provider, Payer

Trends That Matter for New Multiple Sclerosis Value-Based Contract

Posted by Sharon Bender on Jan 16, 2020

Under a value-based contracting agreement believed to be the first of its kind, UPMC Health Plan will receive discounts for two Biogen Inc. multiple sclerosis (MS) drugs — Tecfidera (dimethyl fumarate) and Avonex (interferon beta-1a) — based on patient-reported measures of disability progression. The agreement is also based on research with a panel of key MS stakeholders who identified the most meaningful outcomes in relapsing forms of MS, AIS Health reported.

UPMC's Center for Value-Based Pharmacy Initiatives led the research and developed the value-based contract.
 
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Topics: Industry Trends, Market Access, Data & Analytics

Perspectives on UnitedHealth/Diplomat Deal

Posted by Leslie Small on Jan 9, 2020

Diplomat Pharmacy, Inc., which has been in a tailspin amid mounting financial losses, agreed to a deal with UnitedHealth Group on Dec. 9 that will see the larger firm's OptumRx division purchase the midsized specialty pharmacy provider/PBM, AIS Health reported.

Diplomat's difficulties began to come into focus earlier this year, when the firm disclosed customer losses in its PBM business and "increased competitive pressure in the specialty market." In August, Diplomat said it was "reviewing strategic alternatives" to maximize shareholder value. Then on Dec. 9, UnitedHealth disclosed that it agreed to pay $4 per share for Diplomat's outstanding stock and assume its debt. Equities analysts noted that Diplomat's stock was trading at $5.81 as of market close on the Friday before the transaction was unveiled.
 
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Topics: Industry Trends, Provider, Payer

Radar On Market Access: Health Care Deals May Slow in 2020, but Government Markets Remain Hot

Posted by Jane Anderson on Jan 9, 2020

The pace of health care mergers and acquisitions likely will cool slightly in 2020, some industry experts tell AIS Health. Still, insurers are likely to seek out companies with assets such as care management or information technology solutions, while provider consolidation will continue in certain markets, AIS Health reported.

"We expect that payer M&A will continue into 2020, with a bias toward vertical rather than horizontal deals," says Michael Abrams, managing partner of Numerof & Associates, Inc. "Payers will use such deals to expand into adjacent market spaces to differentiate their offerings as integrated platforms that can deliver superior value, customer experience and innovation."

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Topics: Industry Trends, Provider, Payer

Trends That Matter for New Acute Migraine Medications

Posted by Jane Anderson on Jan 2, 2020

New oral medications for acute migraine — one pending launch and two more that could be approved in the coming months — likely won't shake up formulary coverage for a condition that's largely treated by generic triptan medications, pharmacy benefit experts tell AIS Health.

Eli Lilly and Co. on Oct. 11 received FDA approval for its drug Reyvow (lasmiditan), an oral medication that's the first serotonin (5-HT)1F receptor agonist to be approved for migraine. Meanwhile, Allergan on Nov. 19 said it's on track for December FDA consideration of ubrogepant, an oral CGRP receptor antagonist for acute migraine. Biohaven Pharmaceuticals also has applied for FDA approval on its oral CGRP antagonist rimegepant.
 
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Topics: Industry Trends, Data & Analytics

Perspectives on Dual Eligible SNPs

Posted by Lauren Flynn Kelly on Dec 26, 2019

Through strategic acquisitions, product launches and geographic expansions, Medicare Advantage insurers across the U.S. are offering new Special Needs Plans (SNPs) aimed at improving the lives of members who are dually eligible for Medicare and Medicaid, AIS Health reported.

According to an analysis of the 2020 "landscape" files posted by CMS in September, Chicago health care consultancy Clear View Solutions, LLC, estimates that there are 171 net new SNP IDs, up from 60 net new plans in 2019. And 97 of those net new plans are dual eligible SNPs, compared with 47 D-SNPs that were introduced for 2019.
 
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Topics: Industry Trends, Provider, Payer

Trends That Matter for Anti-VEGF Market

Posted by Angela Maas on Dec 19, 2019

In October 2019, the FDA approved Beovu (brolucizumab-dbll) from Novartis Pharmaceuticals Corp. for the treatment of neovascular (wet) age-related macular degeneration (AMD). The intravitreal injection will compete in a fairly crowded anti-vascular endothelial growth factor (anti-VEGF) market that is led by Eylea (aflibercept) from Regeneron Pharmaceuticals, Inc., AIS Health reported.

Novartis priced Beovu at $1,850 per vial — the same per-dose price as Eylea. Following three initial monthly doses, Beovu can be administered every eight to 12 weeks. Eylea also has three initial monthly doses and then may be administered every four, eight or 12 weeks..
 
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Topics: Industry Trends, Data & Analytics

Radar On Market Access: UnitedHealth Makes Deal to Buy Diplomat as Industry Consolidation Enters 'Second Phase'

Posted by Leslie Small on Dec 17, 2019

Diplomat Pharmacy, Inc., which has been in a tailspin amid mounting financial losses, agreed to a deal with UnitedHealth Group on Dec. 9 that will see the larger firm's OptumRx division purchase the midsized specialty pharmacy provider/PBM, AIS Health reported.

Diplomat's difficulties began to come into focus earlier this year, when the firm disclosed customer losses in its PBM business and "increased competitive pressure in the specialty market." In August, Diplomat said it was "reviewing strategic alternatives" to maximize shareholder value. Then on Dec. 9, UnitedHealth disclosed that it agreed to pay $4 per share for Diplomat's outstanding stock and assume its debt. Equities analysts noted that Diplomat's stock was trading at $5.81 as of market close on the Friday before the transaction was unveiled.

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Topics: Industry Trends, Provider, Payer

Perspectives on Preferred Cost-Sharing Pharmacy Networks

Posted by Leslie Small on Dec 12, 2019

In the Medicare Part D market in 2020, preferred cost-sharing pharmacy networks continue to be king. But because independent pharmacies often find themselves shut out of such arrangements, recently introduced legislation is seeking to change that dynamic.

"The Part D plans have fully adopted preferred networks over the last few years," Adam Fein, Ph.D., president of Pembroke Consulting, Inc., and CEO of Drug Channels Institute, tells AIS Health. "The [retail] chains obviously have some different strategies but are looking for the foot traffic" that comes from offering lower cost sharing as part of a preferred network.
 
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Topics: Industry Trends, Provider, Payer

Trends That Matter for New Cystic Fibrosis Medication

Posted by Judy Packer Tursman on Dec 5, 2019

The FDA recently approved a drug therapy for cystic fibrosis (CF) that is being viewed as a "game-changer" for the roughly nine in 10 patients with the rare, progressive disease who might benefit from it. Where does this leave payers facing rising specialty drug costs across the board? Industry experts predict that most payers likely will cover this latest cystic fibrosis treatment option despite an annual price tag topping $300,000, AIS Health reported.

Vertex Pharmaceuticals, Inc.'s Trikafta (elexacaftor/tezacaftor/ivacaftor and ivacaftor), taken as a twice-daily pill regimen, is the first triple combination therapy available to treat patients with the most common cystic fibrosis mutation. The drug directly addresses the underlying cause of the illness — mutations in the CFTR protein.
 
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Topics: Industry Trends, Data & Analytics